In 1120, a Muslim doctor was on his way to see his patient, the Almoravid ruler of Seville. By the side of the road he saw an emaciated man holding a water jug. The man's belly was swollen, and he was in obvious distress. "Are you sick?" the doctor asked. The man nodded.
"What have you been eating?"
"Only a few crusts of bread and the water from this jug."
"Bread won't hurt you," said the doctor. "It could be the water. Where are you getting it?"
"From the well in town."
The doctor pondered a moment. "The well is clean. It must be the jug. Break it and find a new one."
"I can't," whined the man, "This is my only jug."
"And that thing bulging out there," replied the doctor, pointing to the man's midsection, "is your only stomach. It is easier to find a new jug than a new stomach."
The man continued to protest, but one of the doctor's servants picked up a stone and smashed the jug. A dead frog spilled out with the foul water.
"My friend," the doctor said to the patient, "look what you have been drinking. That frog would have taken you with him. Here, take this coin and go buy a new jug."
When the doctor passed by a few days later, he saw the same man sitting by the side of the road. His stomach had shrunk, he had gained weight, and his color was back. Seeing the doctor, the man heaped praise on him.
-attributed to Ibn Abi Usaybi'a, 13th century
While this demonstration of clear reasoning was taking place in Muslim Spain, medical practice in Christian Europe, hobbled by a mindset that would have seen the doctor's work as a challenge to divine will, offered the sick little more than prayers and comfort, rather than medicine or treatments.
In the East, the spread of Islam, beginning in the seventh century CE., sparked the assimilation of existing knowledge and its development in all branches of learning, including medicine. Arab conquerors rapidly absorbed much from their new subjects. Arabic became to the East what Latin and Greek had been to the West-the language of literature and of the arts and sciences, the common tongue of learned men from the Rann of Kutch to the French border-and the Hajj, or pilgrimage to Makkah, brought hundreds of thousands of pilgrims together each year, facilitating the exchange of ideas, knowledge and books.
Recognizing the importance of translating Greek works into Arabic to make them more widely available, the Abbasid caliphs Harun al-Rashid and his son, al-Ma'mun, sponsored a translation bureau in Baghdad-the Bayt al-Hikmah, or House of Wisdom-starting in the late eighth century, that sent agents throughout Muslim and non-Muslim lands in search of scholarly manuscripts in every language. Rendered into Arabic, these precious documents established a solid foundation for the Muslim sciences, not the least of which was medicine.
|ken welsh / alamy
surgical instruments from a 13th-century Arabic copy of al-Zahrawi's On
As in Greece, medicine in the Muslim world was based on the theory of the four humors that had been advanced by the second-century Greek physician Galen. Each of the four universal elements that comprised the world-earth, air, fire and water-was associated with one of the humors-blood, phlegm, black bile and yellow bile-whose various mixtures defined the different temperaments. When the body's humors were in correct alignment, a person was healthy; when out of balance, he was sick. The task of the doctor, Galen wrote, was to restore this alignment by prescribing changes in diet, exercise or certain activities, or by taking other measures. For example, fever was caused by too much blood, and thus he prescribed bloodletting to remove the excess.
However incorrect, Galen's essentially rationalist view of health and disease found favor in the East, where the Qur'an assured that "for every disease there is a cure." Thus Muslim physicians saw themselves as healers and preservers of health rather than passive witnesses to events with supernatural causes.
While the translators in the House of Wisdom toiled, Muslim doctors developed the bimaristan-later simply maristan-the forerunner of today's hospital. Open to all, it welcomed patients to be treated for, and recover from, a variety of ailments and injuries, including mental illness. The larger maristans were attached to medical schools and libraries, where prospective physicians were taught, examined and, as today, licensed. The maristan became the cradle of Islamic medicine and the means of its dissemination throughout the empire.
Like the hospital, pharmacy as a profession is also an Islamic innovation. In the maristans, trained pharmacists prepared and dispensed remedies that more often than not had some positive effects. Their extensive pharmacopeias detailed the geographical origins, physical properties and methods of application of everything found useful in the curing of disease. By al-Ma'mun's time, the pharmacists (saydalani) were, like doctors, licensed professionals required to pass demanding examinations, and to protect the public from errors and incompetence, government inspectors monitored the purity of their ointments, pills, elixirs, confections, tinctures, suppositories and inhalants. In the maristan, the chief pharmacist held a rank equal to that of the chief of medicine.
But while Abbasid Baghdad, with the House of Wisdom and the first maristans, may have begun the golden age of Islamic medicine, the center of learning and progress began to shift westward in the eighth century, to al-Andalus, today's southern Spain.
|national library of
|By the time this
woodcut showing followers of Albucasis (as Al-Zahrawi was known in
Latin) was produced in 1516 in Spain, his medical legacy was already
more than 500 years old.
The Abbasids had taken power from the Damascus-based Umayyad dynasty. Abdulrahman, grandson of the 10th Umayyad caliph, escaped the massacre of his relatives and in 758 ce took asylum in Spain. Within a few years, this intrepid ruler had carved out a rival caliphate with its capital at Cordoba, and by the late 10th century Cordoba had surpassed Baghdad as the center of intellectual activity in the Islamic world.
Cordoba's 70 libraries, 900 public baths, 300 mosques and 50 maristans were available to all of its one million residents. Cordoba's university, founded in the eighth century, was a premier center of learning, and its library held at least 225,000 volumes. (At that time, the library of the University of Paris held some 400 volumes.) It drew scholars from all over Europe-one of them, Gerbert of Aurillac, later became Pope Sylvester ii, who replaced cumbersome Roman numerals with today's "Arabic" numbers. Al-Andalus was soon home to accomplished and innovative philosophers, geographers, engineers, architects and physicians.
In the western caliphate, doctors differed from their eastern counterparts. Although Cordoba and Baghdad were in close contact intellectually, the western physicians exhibited more independence of thought than their more classics-bound eastern colleagues, offering no blind obedience to either Galen or the Canon of Ibn Sina, the 10th-century Bukhara-born physician who was the Arab world's equivalent of Aristotle and Leonardo. Instead, they challenged and rejected both when their own experience justified it. Their writings and research showed their preference for the concise, the brief and the exact, as contrasted with the discursive, often hair-splitting, subtleties preferred by the savants of the East.
While the western Islamic world produced hundreds of insightful and even brilliant medical men between the ninth and 15th centuries, five stand at the pinnacle of medicine during their eras, and their influences reverberate even now, more than a millennium later.
"The Father of Surgery"
Born in 938 ce just north of Cordoba in Al Zahra, the royal city of Abdulrahman iii, Abu al-Qasim Khalaf ibn al-'Abbas was known to contemporaries as al-Zahrawi, and his name was Latinized to Albucasis. While little is known for certain about his personal life, his surgical acumen was unprecedented.
On the Cutting Edge
A list of major surgical procedures that
Al-Zahrawi describes reads like a compendium of medicine in itself. Among
his "firsts" were:
- Exposure and division of the temporal
artery to relieve certain types of headaches
- Extraction of cataracts
- Guillotine tonsillectomy (as opposed to
the more painful snare or ligature methods)
- Using a hook to extract a polyp from the
- The supine posture for childbirth (now
known as "Walcher's position")
- Application of ligature for bleeding
- Treatment of anal fistulas
- Reduction of a dislocated shoulder
- Removal of thyroid cysts
- Mastectomy to treat breast cancer
- Surgery for breast reduction
|musee atger /
giraudon / bridgeman art library
annotated illustrations of surgical instruments were circulating in
Europe in Latin translation in the 14th century.
Al-Zahrawi only wrote one book, Kitab al-Tasrif li-man 'Ajizja 'an al-Ta'lif (The Arrangement [of Medical Knowledge] for One Who is Unable to Compile [a Manual for Himself]), a compendium of 30 volumes on medicine, surgery, pharmacy and other health topics compiled during a 50-year career. Its last volume, the 300-page On Surgery, was the first book to treat surgery as a separate subject and the first illustrated surgical treatise. Covering ophthalmology, obstetrics, gynecology, military medicine, urology, orthopedics and more, it remained a standard surgical reference in Europe until the late 16th century.
Al-Zahrawi described a vast repertoire (see "On the Cutting Edge," at left) of procedures, inventions and techniques, including thyroidectomy, extraction of cataracts and an innovative method of removing kidney stones by diversion through the rectum that dramatically reduced the mortality rate for the procedure, compared to the method Galen recommended.
The Arrangement of Medical Knowledge was the earliest text to deal with dental surgery in detail, including reimplantation of dislodged teeth. It also described the carving of false teeth from animal bone, as well as how to correct non-aligned or deformed teeth. Al-Zahrawi also detailed procedures still used by today's dental hygienists to remove calculus deposits from teeth.
More prosaically, al-Zahrawi used ink preoperatively to mark the incisions on his patients' skin, now a standard procedure worldwide. He was the first to use catgut for internal sutures, silk for cosmetic surgery and cotton as a surgical dressing. He described, and probably invented, the plaster cast for fractures-a practice not widely adopted in Europe until the 19th century. He produced annotated diagrams of more than 200 surgical instruments, many of which he devised himself. His meticulous illustrations, intended as both teaching tools and manufacturing guides, are the earliest known and possibly the first ever such published diagrams. His best-known inventions were the syringe, the obstetrical forceps, the surgical hook and needle, the bone saw and the lithotomy scalpel-all items in use today in much the same forms.
The Doctor of Seville
The doctor who observed, diagnosed and cured the man by the side of the road at the beginning of this article was Abu Marwan 'Abd al-Malik ibn Zuhr, later Latinized to Avenzoar, who was born in 1091 ce in Seville. Since the Banu Zuhr, as his family was known, had already produced two generations of physicians (and would produce five more), there was no question about his career.
Ibn Zuhr, however, did not merely follow in his ancestors' footsteps. He became the first Muslim scientist to devote himself exclusively to medicine, and his several major discoveries were chronicled in his books Kitab al-Taysir fi 'l-Mudawat wa 'l-Tadbir (Practical Manual of Treatments and Diets) and a treatise on psychology whose title translates Book of the Middle Course Concerning the Reformation of Souls and Bodies, as well as Kitab al Aghdiya (Book on Foods) that describes the health effects of diets, condiments and drinks.
In this body of work, one of his smaller but most effective accomplishments was proof that scabies is caused by the itch mite, and that it can be cured by removing the parasite from the patient's body without purging, bleeding or any other (often painful) treatments associated with the four humors. This discovery sent a shudder through medical science, for it unshackled medicine from strict reliance on the theory of humors and, with that, blind acceptance of Galen and Ibn
Ibn Zuhr also wrote about how diet and lifestyle can help a person avoid developing kidney stones. He gave the first accurate descriptions of neurological disorders, including meningitis, intracranial thrombophlebitis and mediastinal tumors, and he made some of the first contributions to what became modern neuropharmacology. He provided the first detailed report of cancer of the colon. Ibn Zuhr was the first to explain how to provide direct feeding through the gullet or rectum in cases where normal feeding was not possible-a technique now known as parenteral feeding.
Ibn Zuhr introduced the experimental method into surgery, using animals as test subjects-using, for example, a goat to prove the safety of a tracheotomy procedure he devised. He also performed post-mortems on sheep while doing clinical research on how to treat ulcerating diseases of the lungs. Ibn Zuhr is the first physician known to have performed human dissection and to use autopsies to enhance his understanding of surgical techniques.
|bibliotheque de la
faculte de medicine / archives charmet / bridgeman art library (detail)
Italian illustration depicts the presentation of a work by Ibn Zuhr of
Seville, translated into Latin by John of Capua.
Ibn Zuhr established surgery as an independent field by introducing a training course designed specifically for future surgeons before allowing them to perform operations independently. He differentiated the roles of a general practitioner and a surgeon, drawing the metaphorical "red lines" at which a physician should stop during his management of a surgical condition, thus further helping define surgery as a medical specialty. He was also among the first to use anesthesia, performing hundreds of surgeries after placing sponges soaked in a mixture of cannabis, opium and hyoscyamus (henbane) over the patient's face.
Not least, by seeing to it that both his daughter and his granddaughter went into medicine, he became a pioneer in a different way. Though largely limited to obstetrics, these women began a tradition in the Muslim world that accepted females as medical doctors 700 years before Johns Hopkins University graduated the first American female physician.
Doctor and Philosopher
Born in Cordoba in 1126 and at one time a student of Ibn Zuhr, Abu 'l-Walid Muhammad ibn Ahmed ibn Muhammad ibn Rushd was in many respects to the western caliphate what Ibn Sina was to the eastern one. Known in Europe as Averroes, he became known mainly for his works on philosophy. Ibn Rushd's principal medical work, a slender volume called Kitab al-Kulliyat fi al-Tibb (General Rules of Medicine) became an important prˇcis of medicine. Beginning with a brief anatomical survey of the human body, the book continues with sections on the functions of the various organs, systemic diseases, diet, drugs, poisons, baths and the role of exercise in maintaining health. The sections on surgery briefly cover the treatment of abscesses and the use of styptics, cauterization and ligatures. Perhaps most notably of all, he observed that smallpox "is a disease (that) attacks the patient only once"-the first known reference to acquired immunity.
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